Dual vs. mono antiplatelet therapy for acute ischemic stroke or transient ischemic attack with evidence of large artery atherosclerosis

Abstract

Background and purposeCurrent pieces of evidence support the short-term use of dual antiplatelet (DAPT) in minor ischemic stroke or transient ischemic attack (TIA) based on the studies performed in patients with a broad range of non-cardioembolic stroke mechanisms. However, the efficacy and safety of DAPT use in ischemic stroke patients with large artery atherosclerosis (LAA) are still uncertain. We undertook a systemic search and formal meta-analysis to compare DAPT vs. mono-antiplatelet therapy (MAPT) in patients with etiology specifically presumed to be symptomatic LAA.MethodsWe conducted a systemic online search for completed randomized controlled trials that (1) compared DAPT vs. MAPT in patients with acute ischemic stroke or TIA, and (2) were confined to or had available subgroup data regarding population with symptomatic extra- or intracranial artery stenosis. Study-level meta-analysis was performed for outcomes, including ischemic stroke (IS) recurrence, intracranial hemorrhage (ICH), and major bleeding with the Mantel-Haenszel method and random effect models, and was described as risk difference (RD) and 95% CI.ResultsA total of 10 trials including 5,004 patients were pooled. Comparing to MAPT, DAPT significantly reduced IS recurrence (5.99 vs. 9.55%, RD: −3%, 95% CI: −5–0%). Across all agents, out of 100 treated patients, 3 fewer had a recurrent ischemic stroke with DAPT. The safety endpoints including ICH (0.28 vs. 0.32%, RD: 0%, 95% CI: −0–0%) and major bleeding (0.73 vs. 0.51%, RD: 0%, 95% CI: −0–0%) did not differ significantly.ConclusionIn patients with symptomatic large artery extracranial or intracranial atherosclerosis, DAPT was superior to MAPT in preventing IS recurrence without increasing bleeding risks. The optimal DAPT regimens and duration of treatment in this population need to be clarified in further studies.

Dual antiplatelet therapy for ischemic stroke with intracranial arterial stenosis: a systematic review and meta-analysis

“…Despite ongoing debates regarding the safety and efficacy of DAPT in ischemic stroke patients with ICAS, there is currently no consensus on its use ( 4 , 5 , 44 ). Our systematic review, incorporating recent RCTs, shows that DAPT significantly reduced the composite of ischemic and bleeding events, strokes, and cerebral infarctions in these patients.…”

“…This systematic review is subject to limitations. Notably, variability in outcomes was observed, influenced by factors such as the ICAS location and severity, timing of DAPT initiation ( 44 , 53 , 54 ), and duration of therapy ( 4 , 5 , 44 ). These heterogeneities could impact our findings’ reliability, yet they not accounted for in our meta-analysis.…”

Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Ischemic Stroke With Blood Pressure-Dependent Symptoms

“…Asians have a higher risk of ischemic stroke secondary to intracranial atherosclerosis when compared to Caucasians, [ 2 ]. Several ongoing trials such as CHANCE-2 and CAPTIVA have attempted to elucidate the optimal medical management for stroke patients with intracranial atherosclerosis mechanism [ 3 , 4 ]. Despite undergoing medical management, patients with intracranial atherosclerosis remain at a higher risk for recurrent ischemic strokes [ 5 ].…”